Provider Demographics
NPI:1104057694
Name:SPECIALISTS HOSPITAL SHREVEPORT, LLC
Entity type:Organization
Organization Name:SPECIALISTS HOSPITAL SHREVEPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KANDI
Authorized Official - Middle Name:G
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-632-6083
Mailing Address - Street 1:1500 LINE AVENUE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4639
Mailing Address - Country:US
Mailing Address - Phone:318-213-3800
Mailing Address - Fax:318-213-3801
Practice Address - Street 1:1500 LINE AVENUE
Practice Address - Street 2:SUITE 206
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4639
Practice Address - Country:US
Practice Address - Phone:318-213-3800
Practice Address - Fax:318-213-3801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-31
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
335E00000X
LA626282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1702439Medicaid
LA1702439Medicaid
LA190278Medicare Oscar/Certification